A Scoping Review of the Maternal Role at Older Age; Perceptions and Occupations

Motherhood is a meaningful life role among adult women. Occupations within the maternal role of younger mothers have been well documented, but less is known regarding the maternal-role at older age. This review aimed to describe the occupations, activities, and perceptions that older women ascribe to their maternal role. In the future, this information may promote health and wellbeing of older women. A systematic search of peer reviewed articles, that included healthy, community-dwelling mothers, 60 years of age or older, was conducted. Maternal-role occupations and perceptions of older mothers were identified and classified according to the Occupational Therapy Practice Framework (OTPF). Fourteen articles, representing 3102 older mothers, were included. The identified occupations and activities within the maternal role were from two categories: Instrumental Activities of Daily Living (IADL) (such as assistance with daily chores) and social participation (such as sharing holiday rituals). Three themes reflecting maternal-role perceptions were identified: providing support; relationship with children; and motherhood as a never-ending role. Maternal occupations were identified in only a few articles and from only two categories, IADL and social participation. These findings together with the perception that motherhood is a ‘never-ending’ role suggests that further research is needed to better characterize the maternal role of older women from an occupational perspective.


Introduction
As life expectancy continues to grow, the importance of identifying factors contributing to healthy aging increases [1]. Engagement in meaningful occupations, specifically among older adults, has been positively associated with health and wellbeing [2][3][4]. Stav et al. [5], in their systematic review of 59 longitudinal studies, also concluded that the participation of older adults in meaningful occupations, such as leisure, social, and religious activities, is related to positive health outcomes. Evidence in this field, led the World Health Organization to highlight the importance of researching the subjective view point of older adults regarding meaningful occupations, and incorporating this knowledge in health programs aiming to better promote participation [6].
Occupations are sets of activities (such as eating or shopping), carried out in various everyday contexts that people need, want, or are expected to do [7]. The Occupational Therapy Practice Framework (OTPF) defines eight main occupations: Basic and Instrumental Activities of Daily Living (BADL and IADL), social participation, leisure, rest and sleep, education, work, and play. Multiple activities can be involved in the execution of certain occupations; and multiple occupations can be involved in the process of fulfilling meaningful life roles [8].
Motherhood is one of the most common and desired life roles among adult women [9,10]. Mothers frequently identify themselves through motherhood, perceive the maternal role of higher importance and prioritize it over other life roles, such as work or community roles [11,12]. The maternal role is experienced by mothers as extremely meaningful and it includes various occupations and activities, such as caring and assisting children with IADL occupations [13]. Mothering occupations, which vary between woman, are largely influenced by social, cultural, and temporal factors [14,15]. Engagement in occupations within the maternal role interacts with mothers' personal values and perspectives. For example, a mother can perceive feeding, bathing, and dressing a child as caregiving, but can also perceive these occupations as opportunities for teaching knowledge or passing on values to her child [16,17]. Personal values ascribe meaning to occupations within the maternal role, including occupations that are experienced as demeaning or less enjoyable, for example, getting children ready for school, arguing with children, or cleaning up their room. The value of being "a good mother" is reflected in mother's perception that these occupations are important and necessary although sometimes undesired [18]. Sethi [17], discussed a developmental component that is embedded in the maternal role; mothers constantly evolve and mature in the mothering process, as role experience accumulates and as children grow older. Findings from a qualitative study of young mothers support this idea; when comparing two age groups of young mothers, the older mothers expressed less desire for perfection and less guilt regarding the maternal role as opposed to the younger mothers [16].
Despite the recognition of its chronologically developing nature, there seems to be a gap in the research of the maternal role at later stages of women's lives [19]. Our literature search revealed only a few studies that included information regarding the maternal role occupations of healthy older women. Most studies focused on mothers with functional disabilities or mothers to children with disabilities [20][21][22][23]. Older women comprise a large and growing proportion of the older population, and face higher risks of illness and chronic conditions than older men [24,25]. Therefore, it is important to understand the maternal role as a meaningful life role that may motivate older women to participate in daily activities and occupations, and hence maintain or improve their health and wellbeing. The aim of this scoping review is to systematically explore the maternal role of healthy older women. We defined two research questions: (1) What occupations and activities are included in the maternal role among healthy older women? (2) What are the attitudes and perceptions of older mothers regarding mothering occupations at older age? These findings can be used in the future by health professionals, and specifically by occupational therapist practitioners, to enhance participation to help preserve the health and wellbeing of older women.

Materials and Methods
We conducted a scoping review, since this methodology is appropriate when conducting a knowledge synthesis of key concepts within an area of diverse evidence [26]. We followed the methodological framework of Arksey and O'Malley [27] which instructs five sequential steps: (i) Identifying research question; (ii) Identifying relevant studies; (iii) Study selection; (iv) Charting data; and (v) Collating, summarizing, and reporting results. We were additionally guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews (PRISMA-ScR) [28] (see Appendix A).

Eligibility Criteria (Study Selection)
Peer-reviewed, full-text articles that were published in English were included in this scoping review according to the following inclusion criteria. The search was not limited by year of publication. Articles were eligible if they included community dwelling older mothers of healthy children. Mothers were 60 years of age or older (or at least some of the sample was 60 or over) and were independent in daily living. Studies that included only young mothers, or mothers with chronic conditions or disabilities or mothers of children with disabilities were excluded from this review.

Information Sources and Search Strategy (Identifying Relevant Studies)
A search strategy was developed by the research team in consultation with a certified librarian, following the PCC mnemonic (Population, Concept, and Context), recommended by the Joanna Briggs Institute (JBI) guidance for scoping reviews [29]. The search terms were: mothers, mothering, aged OR aging OR age, older, old, adult children, geriatric, and life changes. The search process was conducted using three databases: Medline, PsycINFO, and CINHAL.

Data Items and Data Collection Process
The data collection process was guided by recommendations of Levac [30] and included research team meetings to define the inclusion and exclusion criteria. Two independent raters reviewed the articles in two stages: titles and abstracts were reviewed first, then the relevant full texts were reviewed. Disagreements regarding inclusion of the articles were reviewed by two other raters, to make the final decision.

Charting the Data
The following data were extracted from the articles (a) author(s), (b) year of publication and country, (c) study question(s) or aim of the study, (d) participants, (e), study method and tools. In addition, the extracted data were examined for relevant information regarding occupations and perceptions related to the maternal role, according to the research questions. Maternal-role occupations and perceptions were then classified and organized according to OTPF: Domain and process 3rd Edition [8]. The occupations and perceptions that were identified fit the definition of IADL and Social Participation. Discrepancies regarding categorization were discussed between all co-authors until agreement was reached.

Results
The systematic search yielded 142 articles, 117 after removal of duplicates and 89 records were excluded following the screening process due to not meeting the inclusion criteria (see Figure 1 PRISMA diagram). After the full-text of 28 articles were assessed for eligibility, 14 articles representing 3102 older mothers were included in this scoping review. These articles described studies which utilized qualitative (n = 5), quantitative (n = 8), and mixed method (n = 1) research methodology. All qualitative studies used interviews as the main research tool, mostly semi-structured, and one study conducted focus groups as well. The quantitative studies used self-report scales for assessing research measures (such as closeness in mother-child relationship or maternal support).
Six of the fourteen studies included only older mothers, the remaining studies included younger mothers as well, ranging from mothers aged 32 to 89 years old. The articles included were conducted by researchers from various fields: sociology (n = 5), social work (n = 3), gerontology (n = 2), psychology (n = 2), public health (n = 1), and occupational therapy (n = 1), and originated worldwide: North America (n = 8), Europe (n = 4), and Asia (n = 3) (see Table 1). As can be seen in Table 1, samples of the 14 articles included older mothers (n = 14 mothers to 803), to investigate varied study aims.
The maternal role occupations and perceptions that were identified in the articles matched the definitions of IADL and social participation occupations. IADL occupations are activities that support daily life within the home and community, including health and financial management and the care of others. Social participation occupations refer to activities that support the engagement in social situations and contexts, including in the family or the community [8].   To determine whether quality of mother-daughter relationship is related to mutual support given with respect to support given by daughters to mothers. To explore the ways in which support from daughters to mothers is initiated and given and the types of support given from the perspective of mothers, and to explore the perspective of daughters in relation to their mothers' feelings Psychology/Canada Quantitative Older mothers (n = 43), age range 60-89, mean age 73. Adult daughters (n = 43) age range 29-67, mean age 44.

Suitor 2006 [36]
To explore the extent of within-family differences in older mothers' support to children, and explain differences using factors drawn from between-family designed studies.

Suitor 2007 [37]
To identify factors that distinguish between mothers who report having a favorite child and mothers that report equal preference among all their children To explore the perspective of mothers-in-law of interactions with and feelings toward their daughters-in-law, and the son's role in those interactions.

Social Work/United States Quantitative
Older mothers (n = 267), from various races and religions, who's sons are married to a living daughter in law. Age mean 63, (SD = 10; range: 37-88)

Occupations within the Maternal Role of Older Women
IADL occupations within the maternal role were identified in 12 of the 14 articles. The focus in these studies was on the support older mothers give their adult children [32,34,36,[38][39][40][41][42][43]. The IADL occupations included assisting children with cooking or shopping, running errands for the children, tending their home, providing them with financial support, and caring for the grandchildren. Other studies described exchanged support, which relates to support given by the adult children to their older mothers [31,33,35]; for example, finding a place for the mothers to live and taking care of the mothers when they were ill.
Social participation occupations within the maternal role were identified in eight articles. These studies highlighted social events and activities in which older mothers engage together with their children. Mothers and their children, participated in fun and enjoyable activities such as shopping, travelling, and gift giving. They visit their children and share holiday rituals together. Mothers described being in contact frequently with their children, sharing thoughts and opinions, and being involved in their children's lives [31][32][33]35,37,38,40,44]

Perceptions and Attitudes of Older Women toward the Maternal Role
Three themes were identified in the articles reflecting mothers' perceptions and attitudes towards the maternal role and are described below and in appear in Table 2. Theme I. Perceptions of Providing support were identified in seven articles. These articles described the value the mothers ascribed to supporting their children; for example, feeling rewarded by providing support to children. The mothers' perceptions towards receiving support (exchanged support) were perceived as ambivalent, not all mothers felt comfortable with support given to them by their children [31,35,36,40,42,43]. Theme II. Perceptions of having a relationship with their children emerged from five articles. Close relationships with children are highly valued by mothers, sometimes perceived to reconcile the hardship of earlier stages of motherhood [32,33,38]. Closeness is also described as a complex attribute of the relationship between older mothers and their children; for example, Suitor et al. [37] discussed the phenomenon of mothers' differentiation of closeness among their children and factors that contribute to it. Blieszner et al. [33], described older mothers' experiences of a relationship with their daughters, which had positive aspects of closeness and companionship, but also aspects of conflict, complexity, and ambiguity; The mother's relationship with her own child is also described to be extended to their spouse (children-in-law) [44]. Theme III. Motherhood as a never-ending role was discussed in two articles. Mothers described feeling responsible and accountable for upbringing of the children, the child's growth, and success throughout life. The development of the maternal role over time is also demonstrated by the extension of the perceived responsibility towards the daughter/son in-law, as well as to the grandchildren. Mothers reported perceiving increased importance of the maternal role as the years go by, as opposed to other life roles (such as professional roles) that are perceived less as important over time [34,38]. Table 2. Occupations and perceptions within the maternal role identified in the 14 articles.

Discussion
The goal of this review was to explore the daily occupations and perceptions associated with older women's maternal role. We identified two categories of occupations within the maternal role: IADL and social participation, as well as three themes reflecting perceptions regarding the maternal role: providing support; relationship with children; and motherhood as a never-ending role. A certain symmetry is apparent between the identified occupations and perceptions: IADL occupations, which include caring for others, correspond with perceptions of providing support to children; and social participation occupations correspond with mothers' perception of the relationships with their children, which naturally occurs in social contexts. This may suggest an interweaving dynamic interaction between mothers' values and their daily occupations. Personal values reflect one's goals or desires and include beliefs about what is good, correct, or important to do [45]. The way people choose which daily occupations they engage in, and the way they experience their engagement, is largely based on their personal values [46]. The perception that providing support is an essential part of motherhood, may reflect the value of 'giving', which has been previously associated with the maternal role of younger women [18,47]. This value may lead mothers to engage in the wide range of IADL occupations, which provides support to their children. However, since personal values are strongly affected by social contexts and cultural factors [48], it is expected that the choices of occupations and engagement within the maternal role will vary according to individual, social, and cultural factors. Schwarz et al. [39] for example, described the traditional Chinese obligation of adult children to support their older parents. Therefore, an older Chinese mother who identifies with this value may appreciate the receiving of support from her adult child, while the option of providing support to the child may be perceived negatively in relation to fulfilling her maternal role. Similarly, the identified value of having a close relationship with children may lead older mothers to engage in the social participation occupations that were identified in the reviewed articles.
The importance of understanding values of older adults, is in accordance with the recent global movement towards healthy aging. Enabling older adults to do what they value, supports current definitions of healthy aging, which expands the concept of health beyond traditional medical measures [6,49,50]. Participation, which means involvement in life situations, is the ability of older adults to perform daily activities and fulfill meaningful life roles. Participation is considered an important indicator of human health and wellbeing, therefore maintaining the participation of older adults and specifically of older women, is of paramount importance. According to the WHO's International Classification of Functioning and Disability (ICF) model, participation is the consequence of interactions between an individual's health status, personal, and environmental contextual factors [51]. Social participation of older adults has been found to be positively associated with self-rated physical and mental health [52,53]. Occupations of social participation were identified in eight of the reviewed articles, demonstrating the importance of social participation as part of the maternal role of older women. Participation in activities that contribute to others has also been found to be associated with enhanced outcomes of health and wellbeing of older adults [54][55][56]. For example, Forssen and Carlstedt [38] described the impact of close relationships with children and grandchildren on the perceived health of older mothers, which was expressed by feelings of self-worth that helped to endure pain, and hence increase their participation. Schwarz et al. [39], reported associations between support provided to children and the older mothers' life-satisfaction. This suggests that the maternal role, as a meaningful life role, holds the potential to motivate older women, who are at risk of illness and chronic conditions [25,57], to participate in meaningful occupations, and hence achieve better health outcomes. Since the meaning that a person attributes to participation in activities is subjective and often covert [58], identifying the values and perspectives that may lead mothers to make personal choices regarding the engagement in these occupations, is important. This scoping review highlights the gap in the research of motherhood in older age, specifically research from an occupational perspective. Despite our wide search of year of publication, only fourteen eligible articles were identified and only five of them were published within the last ten years. Only one study specifically aimed to explore maternal occupations of older women, while the other studies partially reported on this topic within their original aims. In addition, only two maternal role occupations of the eight occupations defined by the OTPF, were identified in the reviewed articles. This possibly reflects paucity in the research of the maternal role at older age, rather than restricted participation in occupations of older mothers. Occupations such as leisure or BADL were not described in the articles and should be further researched.

Limitations and Strengths
This is the first scoping review that aimed to identify the occupations and daily activities within the maternal role of older women. The articles included in the review were elicited from a wide range of research fields and were examined through the unique occupational perspective, using the OTPF [8]. Three databases were used for the searching process, while focusing exclusively on peer reviewed articles published in English language. It is possible that by using additional databases, by using alternative search terms or inclusion criteria other search results would have been found. The limited number of articles included in this review calls for a cautious interpretation of conclusions.

Conclusions
The scarce literature found in this scoping review supports the perception that being a mother is a meaningful and never-ending life role. Further research is needed in order to characterize the maternal role of older women, specifically through an occupational perspective. This information may be used to promote the health and wellbeing of older mothers, by enhancing their participation in meaningful occupations and life roles.  Selection of sources of evidence 9 State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review. 3 Data charting process 10 Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators. 3

Data items 11
List and define all variables for which data were sought and any assumptions and simplifications made. 3 Critical appraisal of individual sources of evidence 12 If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate). N/A Synthesis of results 13 Describe the methods of handling and summarizing the data that were charted. 3

Selection of sources of evidence 14
Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram. 4 Characteristics of sources of evidence 15 For each source of evidence, present characteristics for which data were charted and provide the citations.

5-7
Critical appraisal within sources of evidence 16 If done, present data on critical appraisal of included sources of evidence (see item 12). N/A

Results of individual sources of evidence 17
For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives. 7-9 Synthesis of results 18 Summarize and/or present the charting results as they relate to the review questions and objectives. 9

Summary of evidence 19
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups. 9 Limitations 20 Discuss the limitations of the scoping review process. 10

Conclusions 21
Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps. 10

Funding 22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review. 11